Background: At our institution, no current standard exists for teaching rounds’ structure or content, which is largely at the discretion of the attending physician. The purpose of this study was to illustrate the “anatomy” of inpatient rounds as a needs assessment for future process improvement efforts.
Methods: We performed a descriptive cross-sectional study of general medicine inpatient teaching rounds at a single academic center over a four-month period (Dec., 2018 to Mar., 2019). Five internal medicine teams were observed by trained volunteers during teaching rounds on acute care units. Volunteers accompanied rounds and recorded data including the encounter type (new presentation, follow-up, discharge), unit location, location of rounds (bedside, hallway, team workroom), identity of the “presenter” (student, intern, resident), presentation duration, time spent in the patient’s room, total encounter duration, and travel time between encounters. Also recorded were activities that are locally considered best practice, including RN participation, review of EMR data, placement of orders, explicit teaching by the attending physician or resident, updating a patient-centric whiteboard. Physician interruptions were also tabulated. No patient data were recorded. We performed frequency analyses on activities observed during rounds.
Results: 1631 unique patient encounters were observed. The majority of encounters were follow-up visits (91%). Presentations occurred predominantly in the hallway outside the patient room (84%), and less frequently in team workrooms (8%) or inside patient rooms (7%). Interns were the most frequent presenters (48%) followed by residents (28%) and students (25%). The median and average presentation times were 5 and 7 minutes, respectively, and ranged from 0 to 47 minutes. The median and average encounter durations were 13 and 14 minutes, respectively, and ranged from 1 to 70 minutes. The median and average time spent in the patient’s room were 6 and 7 minutes, respectively, and ranged from 0 to 38 minutes. The frequency of other encounter activities included delivery of explicit teaching to the team by the attending physician or resident (62%), nurse participation (55%), review of EMR data (51%), placement of orders in the EMR (34%), and updating of a patient-centered board (29%). Physician interruptions occurred in 24% of encounters. The median and average travel time between encounters was 2 minutes and ranged from 0 to 7 minutes.
Conclusions: Although internal medicine attending rounds have long been a cornerstone of hospital-based patient care and medical education, few studies have directly observed their structure or content. These data describe the current state of our institution’s teaching rounds, whose average encounter lasts fewer than 15 minutes, include presentations that typically occur outside patient rooms, involve multiple presenters, usually incorporate overt teaching, often include nurse participation and review of EMR data, and less frequently contain electronic order placement or the updating of patients’ whiteboards. The relatively low frequencies of several ‘best practices’ provide an opportunity to better define what, in fact, constitute best practices and understand barriers to their actualization. Future work will include refining expectations and role descriptions for team members and analyzing factors that may promote adherence to updated best practices.